CHRONIC SUPPURATIVE OTITIS MEDIA

DR. DAVIS THOMAS

OBJECTIVES:At the end of this class, you should be able

to describe:

•Lining epithelium of the middle ear cleft•Definition of CSOM and Cholesteatoma•Types of CSOM and their clinical features•Theories of Cholesteatoma•Investigations for CSOM•Treatment of CSOM

RELEVANT ANATOMY

MIDDLE EAR CLEFT

LINING EPITHELIUM OF MIDDLE EAR CLEFT

• Antero inferiorly – ciliated columnar epithelium

• Posteriorly – cuboidal type

• Epitympanum and mastoid air cells – flat nonciliated epithelium (pavement epithelium)

DEFINITION OF CSOM• Chronic suppurative otitis media is a long

standing infection of a part or

whole of the middle ear cleft characterised by

continuous or intermittent

discharge through a persistent tympanic membrane

perforation.

EPIDEMIOLOGY•Incidence is higher in developing

countries

•Predisposing factors: Poor socio-economic status, poor nutrition, lack of health education

•Affects both sexes

•All age groups

•In India overall prevalance rate is : Rural: 46 per thousand Urban : 16 per thousand

•CSOM is the single most important cause of hearing impairment in rural population

TYPES OF CSOMSafe Type Or Tubo Tympanic Disease

Unsafe Type Or Attico Antral Disease

Active (Mucosal / Squamous)

Inactive (Mucosal / Squamous )

Healed

TUBOTYMPANIC DISEASE

•Disease confined to eustachian tube , anterior and inferior part of mesotympanum and hypotympanum

•Usually starts in childhood , so safe type is common in that age group

•Presents with central perforation•No underlying osteitis or osteomyelitis

AETIOLOGY

Tubotympanic Type

• Sequelae of acute otitis media

• Ascending infections via the eustachian tube

• Nasal Allergy

• GERD

• Cranio facial abnormalities

•Autoimmune disease

BACTERIOLOGY•Pseudomonas aeruginosa •B.Proteus• Esch.coli •Staph. Aureus •Bacteroides fragilis •Anaerobic streptococci.

SYMPTOMS•Ear Discharge

•Hearing Loss

•Ear Pain

•Fever

SIGNS•Profuse mucopurulent discharge, non foul

smelling, not blood stained.•Hearing loss.•Central Perforation.•Middle ear mucosa – congested.•Polyp•Ossicular chain – erosion.•Tympanosclerosis

TYPES OF PERFORATIONCENTRAL PERFORATION:• Perforation in the pars tensa

sorrounded all around by pars tensa

MARGINAL PERFORATION:

• Perforation in the pars tensa surrounded partly by pars tensa and partly by bone

ATTIC PERFORATION:• Perforation in the pars

flaccida

ROUND WINDOW SHIELDING EFFECT

• Patient hears better in the presence of discharge rather than dry ear

• Effect is produced by discharge, by maintaining phase differential

• In dry ear, sound waves strike both the Oval and Round windows simultaneously, thus cancelling each other’s effect with no movement of perilymph, and thus, no hearing.

STAGES FEATURES

ACTIVE STAGE Discharging at the time of examination.

QUIESCENT STAGE In the recent past, discharge present but there is no discharge now.

INACTIVE STAGE No discharge for 3- 6 months.Dry ear.

HEALED STAGE TM Perforation has healed.Permanently controlled middle ear infection.

ATTICO ANTRAL DISEASE•Chronic inflammatory condition of the

middle ear cleft confined to posterior part of the mesotympanum , attic and antrum associated with bone eroding disease or cholesteatoma charactersied by thick, purulent, scanty, foul smelling, blood stained persistent discharge and may be associated with perforation in pars flaccida

CHOLESTEATOMA•It is a cystic bag like structure lined by

stratified squamous epithelium containing desquamated epithelial debris lying on a fibrous tissue stroma of variable thickness

•Skin in the wrong place

•Synonym: keratoma, epidermosis

THEORIES OF CHOLESTEATOMA FORMATION

1. Congenital cell rests

2. Invagination theory: (Wittmack) • Invagination of TM

from attic or posterosuperior part of pars tensa

3. Epithelial invasion theory

(Habermann)

Squamous epithelium from TM migrates to middle ear via TM perforation

4. Basal cell hyperplasia theory:

• Infection or inflammation

• Basal membrane breaks

• Squamous epithelium invade into sub epithelial tissue in pars flaccida like epithelial cones forming microcholesteatoma

• This enlarges and perforates secondarily through the TM

5. Squamous metaplasia theory: •Cuboidal epithelium can undergo

metaplasia to sq.epithelium

•Middle ear cuboidal epithelium is pluripotent can be stimulated by inflammation to become keratinising sq.epithelium

TYPES OF CHOLESTEATOMA•Congenital

•Acquired

- primary

- secondary

COMMON SITES OF CHOLESTEATOMA• Most common sites of origin of acquired

cholesteatomas are

1. Posterior epitympanum2. Posterior mesotympanum3. Anterior epitympanum

PATHOLOGY1. Cholesteatoma2. Osteitis and granulation tisue3. Ossicular necrosis4. Cholesterol granuloma

ATTICO ANTRAL DISEASE SYMPTOMS•Ear Discharge•Hearing Loss•Bleeding •Ear Ache •Dizziness•Tinnitus•Symptoms Of Complications

PARS TENSA CHOLESTEATOMA SIGNS•Retraction Pockets•Cholesteatoma Flakes•Granulation Tissue•Polyp•Hearing Loss

•Single layer of cuboidal epithelium•Crowded structures•Improper drainage

•Bony necrosis by cholesteatoma•Gram negative infection of keratin debris•Cholesteatoma itself foul smelling

WHY IS ATTICOANTRAL DISEASE UNSAFE?

WHY IS CHOLESTEATOMA FOUL SMELLING?

INVESTIGATION• Examination under microscope • Pus for C/S• Audiological Assessment• X-ray both Mastoids• CT Scan Temporal bone • Basic Investigations • X-ray PNS• Diagnostic Nasal Endoscopy • Eustachian Tube Function Tests

EXAMINATION UNDER MICROSCOPE

• To confirm Otoscopic findings

• Site & size of perforation

• Margin of perforation

• Appearance of Middle ear

• Presence of Polyp & granulation Tissue and its site

PURE TONE AUDIOGRAM • Identifying the

presence or absence of auditory functions

• Differentiating conductive from sensorineural hearing loss

• Degree of hearing loss

X-RAY BOTH MASTOIDS • Pneumatisation of

mastoid air cells

• Hazziness / clouding of air cells

• Low lying tegmen or anteriorly lying sinus plate

BASIC INVESTIGATIONS • Complete hemogram : Hb, TC, DC, BT, CT,

ESR

• B. Sugar

• B. Urea, S. Creatinine

• Urine analysis

• ECG

• X-Ray Chest PA view

X-RAY PNS

DIAGNOSTIC NASAL ENDOSCOPY

EUSTACHIAN TUBE FUNCTION TESTS

• Valsalva Test

• Politzer Test

• Catheterisation

• Toynbees test

• Tympanometry

• Radiological Test

MEDICAL TREATMENT• Short term goals : Elimination of infection

Control of otorrhoea• Long term goals :- Improvement of hearing Eventual healing of TM• Aural Toileting - Dry Mopping

Wet mopping Suction irrigation under

microscope• Topical Antibiotics • Systemic Antibiotics

CAUSES OF FAILURE OF MEDICAL TREATMENT

• Poor drainage of inflammatory exudate from the middle

ear

• Presence of persistent osteitis with mastoid granulation

• Virulent & resistant organisms

• Reinfection via Eustachian tube – adenoid, sinuses

• Allergy

• Mastoid reservoir

CHEMICAL CAUTERIZATION(MEDICAL MYRINGOPLASTY)

•Trichloroacetic acid•Principle : The epithelium covering the

margin of the perforation is destroyed and exposing the fibroblasts• Mild irritations induces hyperemia and

secondary fibroblast proliferations

•Used in dry small to medium perforations•Several sittings may be necessary

•Medical Treatment For Cholesteatoma :-• Topical antibiotics with aural toileting• Suction clearance• Application of silver nitrate to granulation tissue• Antimetabolite - 5 – fluorouracil• Reduces the activity of squamous epithelium & curtail the production of keratin debris

•Ventilation Tubes In Attic Retractions

SURGICAL PROCEDURES MYRINGOPLASTY • An operation performed to repair or reconstruct

the TM

TYMPANOPLASTY• An operation performed to eradicate disease in

the middle ear and to reconstruct the hearing mechanisms with out mastoid surgery, with or without TM grafting.

OSSICULOPLASTY• An operation performed to repair or reconstruct

the ossicular chain

MYRINGOPLASTY•Prerequisites

▫Dry ear▫Good cochlear reserve▫Normal ET function▫Predominantly conductive hearing loss▫No cholesteatoma

•Types ▫Grafting techniques – onlay, underlay

TYMPANOPLASTY• TYPE I :

-intact ossicular chain. -sound protection for round window.

• TYPE II:-slight defect of the ossicles.-middle ear is of about normal size.

• TYPE III: - malleus and incus are extremely eroded

- columella effect.

• TYPE IV: - mobile stapes foot plate.

- sound pressure transformation is given up.

• TYPE V: - Fixed stapes foot plate.

- sound pressure through fenestration.

CLOSED OR CANAL WALL UP PROCEDURES

• CORTICAL MASTOIDECTOMY

An operation performed to remove disease from the mastoid antrum and air cell system with preservation of an intact posterior meatal wall without disturbing the middle ear contents.

• COMBINED APPROACH TYMPANOPLASTY (Tympanoplasty with CWU Mastoidectomy)

An operation performed to remove disease from the middle ear and mastoid by way of a) the mastoid, b) posterior tympanotomy, c) transcanal route, followed by reconstruction of middle ear transformer mechanism

OPEN OR CANAL WALL DOWN PROCEDURES

• RADICAL MASTOIDECTOMYAn operation performed to eradicate all middle ear and mastoid disease, in which the mastoid antrum and air cell system, aditus, attic and middle ear are converted into a common cavity, exteriorized to the external meatus. During the procedure, the TM, malleus, incus are removed leaving only stapes footplate

• MODIFIED RADICAL MASTOIDECTOMYIt is a modification of Radical mastoidectomy which is performed to eradicate the disease in mastoid, aditis, attic and the whole area exteriorized into the meatus by removing the bridge and reducing the facial ridge while preserving the middle ear contents.

MODIFIED RADICAL MASTOIDECTOMY

•Indications• Cholesteatoma involving mastoid air cells• Cholesteatoma in only hearing ear• Recurrence of cholesteatoma after closed cavity procedure• Unreconstructable posterior canal wall• Otologic or CNS complications • Poor ET function

RADICAL MASTOIDECTOMYINDICATIONS:

•Unresectable cholesteatoma extending down to eustachian tube or into petrous apex

•Promontory cochlear fistula•Perilabyrinthine cholesteatoma that

cannot be removed and must be cleaned or inspected periodically

•Temporal bone neoplasm

Canal wall up procedure

Canal wall down procedure

Meatus Normal Widely open communicating with mastoid

Dependence Does not require routine cleaning

Requires regular cleaning

Recurrence or residual disease

High rate of recur / residual disease

Low rate

Second look surgery After 6 months Not required

Patients limitations Nil Swimming curtailed

Auditory rehabilitation

Hearing aid Difficult to fit hearing aid